Provider Demographics
NPI:1013960129
Name:OTOADESE, EROMOSELE ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:EROMOSELE
Middle Name:ANTHONY
Last Name:OTOADESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2660
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2660
Mailing Address - Country:US
Mailing Address - Phone:319-233-6621
Mailing Address - Fax:319-233-2164
Practice Address - Street 1:1753 W RIDGEWAY AVE STE 111
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4588
Practice Address - Country:US
Practice Address - Phone:219-233-6211
Practice Address - Fax:319-233-2164
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28663208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA46994OtherWELLMARK INS PLAN
IA2091736Medicaid
IA421417307C4OtherJOHN DEERE HEALTH INS PLA
IA421417307C4OtherJOHN DEERE HEALTH INS PLA
IA2091736Medicaid